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Latest revision as of 05:11, 7 August 2024

Id2.16.840.1.113883.10.22.2.2Effective Date2017‑04‑11
StatusKorange.png Under pre-publication reviewVersion LabelSTU1
NameIPSCDAauthorDisplay NameIPS CDA author
Description

A CDA document shall have at least one author. Authors could be either human (ClinicalDocument/author/assignedAuthor/assignedPerson) either devices (ClinicalDocument/author/assignedAuthor/assignedAuthoringDevice).

For definition “The author element represents the creator of the clinical document. If the role of the actor is the entry of information from his or her own knowledge or application of skills, that actor is the author. If one actor provides information to another actor who filters, reasons, or algorithmically creates new information, then that second actor is also an author, having created information from his or her own knowledge or skills. [From Implementation Guide for CDA Release 2: Imaging Integration – UV Realm, March 2009].

According to this definition, not any device that generates the electronic document has to be considered as an author:

  • a spider collecting and filtering information from different repositories, according to defined rules and policies, for the scope of creating a Patient Summary is definitely a document author (and in some cases the only one );
  • an application that transforms a Patient Summary record into this CDA format may not be an author;
  • For cross-border exchange purposes, a device, which modifies the concepts conveyed (e.g. applying code system mappings), should appear as one of the authors. In this case (document generated through a transformation process) the authors of the parent (original) patient summary should appear as authors as well.

Further to this, authorship can give information about the nature of Patient Summary :

  • if there is a person author only, then the Patient Summary is the result of a practitioner clinical act;
  • if there are device authors only, the summary was automatically generated according to well defined rules defined by the responsible organization.
The CDA standard allows to provide detailed information about what was authored by whom in the Patient Summary, allowing the specification of authorship at the whole document level, at the section level and also at the entry level. In any case it is not required to repeat this information for each of the mentioned levels, taking advantage of the context conduction propriety.
In fact “context that is specified on an outer tag holds true for all nested tags, unless overridden on a nested tag. Context specified on a tag within the CDA body always overrides context propagated from an outer tag. For instance, the specification of authorship at a document section level overrides all authorship propagated from outer tags.” (HL7 CDA R2 Standard).
ClassificationCDA Header Level Template
Open/ClosedOpen (other than defined elements are allowed)
Uses
Uses 2 templates
Uses as NameVersion
2.16.840.1.113883.10.22.9.2IncludeKorange.png IPS CDA Device (STU1)DYNAMIC
2.16.840.1.113883.10.22.9.1IncludeKorange.png IPS CDA Organization (STU1)DYNAMIC
RelationshipAdaptation: template 2.16.840.1.113883.10.12.102 CDA author (2005‑09‑07)
ref
ad1bbr-
Example
Human Author
<author>
  <time value="201212290600+0100"/>  <assignedAuthor>
    <id root="2.16.840.1.113883.2.9.4.3.2" extension="RSSMRA00A01F205F" assigningAuthorityName="Ministero Economia e Finanze"/>    <code code="221" codeSystem="2.16.840.1.113883.2.9.6.2.7" codeSystemName="ISCO" displayName="Medico"/>    <addr use="WP">
      <streetAddressLine>Viale della Cristallina 3</streetAddressLine>      <city>Bologna</city>      <state>BO</state>      <postalCode>40121</postalCode>      <country>IT</country>    </addr>
    <telecom use="WP" value="tel:+39-051-34343434"/>    <assignedPerson>
      <name>
        <given>Paolo</given>        <family>Rossi</family>      </name>
    </assignedPerson>
    <representedOrganization>
      <!-- template 'IPS CDA Organization' (dynamic) -->
    </representedOrganization>
  </assignedAuthor>
</author>
Example
Device Author
<author>
  <time value="201212290600+0100"/>  <assignedAuthor>
    <id root="1.2.3.999" extension="__example only__"/>    <addr use="WP">
      <state>Castilla-La Mancha</state>      <city>Toledo</city>      <precinct>Toledo</precinct>      <country>ES</country>      <postalCode>45071</postalCode>      <streetAddressLine>Av. Río Guadiana, 4</streetAddressLine>    </addr>
    <telecom nullFlavor="NI"/>    <assignedAuthoringDevice classCode="DEV" determinerCode="INSTANCE">
      <softwareName displayName="Turriano"/>    </assignedAuthoringDevice>
    <representedOrganization classCode="ORG" determinerCode="INSTANCE">
      <id root="1.2.3.999" extension="__example only__"/>      <name>SESCAM</name>      <telecom use="WP" value="tel:+34925274100"/>      <addr use="WP">
        <state>Castilla-La Mancha</state>        <city>Toledo</city>        <precinct>Toledo</precinct>        <country>ES</country>        <postalCode>45071</postalCode>        <streetAddressLine>Av. Río Guadiana, 4</streetAddressLine>      </addr>
    </representedOrganization>
  </assignedAuthor>
</author>
ItemDTCardConfDescriptionLabel
hl7:author
1 … *R(IPS...hor)
Treetree.png@typeCode
cs0 … 1FAUT
Treetree.png@context​Control​Code
cs0 … 1FOP
 Example<author>
  <time value="201212290600+0100"/>  <assignedAuthor>
    <id root="2.16.840.1.113883.2.9.4.3.2" extension="RSSMRA00A01F205F" assigningAuthorityName="Ministero Economia e Finanze"/>    <addr use="WP">
      <streetAddressLine>Viale della Cristallina 3</streetAddressLine>      <city>Bologna</city>      <state>BO</state>      <postalCode>40121</postalCode>      <country>IT</country>    </addr>
    <telecom use="WP" value="tel:+39-051-34343434"/>    <assignedPerson>
      <name>
        <given>Paolo</given>        <family>Rossi</family>      </name>
    </assignedPerson>
  </assignedAuthor>
  <representedOrganization>
    <!-- template 'IPS CDA Organization' (dynamic) -->
  </representedOrganization>
</author>
Treetree.pnghl7:functionCode
CE.IPS0 … 1R(IPS...hor)
Treetree.pnghl7:time
TS.IPS.TZ1 … 1RThe author/time element represents the start time of the author’s participation in the creation of the clinical document. (IPS...hor)
 Example<time value="201212290600+0100"/>
Treetree.pnghl7:assignedAuthor
1 … 1R(IPS...hor)
Treeblank.pngTreetree.png@classCode
cs0 … 1FASSIGNED
Treeblank.pngTreetree.pnghl7:id
II1 … *RAuthor Identifier(s)(IPS...hor)
Treeblank.pngTreeblank.pngTreetree.png@nullFlavor
cs0 … 1 
Treeblank.pngTreetree.pnghl7:code
CE.IPS (extensible)0 … 1RA code, which identifies the profession/competence/specialty of the author when it is a person.(IPS...hor)
 CONF
The value of @code should be drawn from value set 2.16.840.1.113883.11.22.53 IPS Healthcare Professional Roles (DYNAMIC)
 Example<code code="221" codeSystem="2.16.840.1.113883.2.9.6.2.7" codeSystemName="ISCO" displayName="Medical doctors"/>
Treeblank.pngTreetree.pnghl7:addr
AD.IPS1 … *R(IPS...hor)
 Example<addr use="WP">
  <streetAddressLine>Viale della Cristallina 3</streetAddressLine>  <city>Bologna</city>  <state>BO</state>  <postalCode>40121</postalCode>  <country>IT</country></addr>
Treeblank.pngTreetree.pnghl7:telecom
TEL.IPS1 … *R(IPS...hor)
Treeblank.pngTreeblank.pngTreetree.png@use
set_cs0 … 1 
 CONF
The value of @use shall be drawn from value set 2.16.840.1.113883.1.11.201 TelecommunicationAddressUse (DYNAMIC)
Treeblank.pngTreeblank.pngTreetree.png@value
url0 … 1 
 Example<telecom use="WP" value="tel:+39-051-34343434"/>
 Example<telecom nullFlavor="NI"/>
Choice1 … 1Elements to choose from:
  • hl7:assigned​Person
  • hl7:assigned​Authoring​Device
Treeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
0 … 1C(IPS...hor)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FPSN
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
PN1 … *RName of the person (e.g. the Healthcare Professional)  authoring this document(IPS...hor)
 Example<name>
  <given>John</given>  <family>Español Smith</family></name>
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:family
1 … *R(IPS...hor)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:given
1 … *R(IPS...hor)
Treeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Authoring​Device
0 … 1C(IPS...hor)
 Example<assignedAuthoringDevice classCode="DEV" determinerCode="INSTANCE">
  <softwareName displayName="Turriano"/></assignedAuthoringDevice>
Included from 2.16.840.1.113883.10.22.9.2 IPS CDA Device (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FDEV
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CE0 … 1(IPS...hor)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:manufacturer​Model​Name
SC0 … 1(IPS...hor)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:softwareName
SC0 … 1(IPS...hor)
Treeblank.pngTreetree.pnghl7:represented​Organization
0 … 1R(IPS...hor)
Included from 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC)
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FORG
Treeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs1 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … *R(IPS...hor)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@nullFlavor
cs0 … 1 
Treeblank.pngTreeblank.pngTreetree.pnghl7:name
ON1 … 1R(IPS...hor)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@nullFlavor
cs0 … 1 
Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL1 … *R(IPS...hor)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@use
set_cs1 … 1R
 CONF
The value of @use shall be drawn from value set 2.16.840.1.113883.1.11.201 TelecommunicationAddressUse (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@nullFlavor
cs0 … 1 
 ConstraintIf there is no information, the nullFlavor attribute shall have a value of 'NI' and the "value" and "use" attributes shall be omitted, otherwise the nullFlavor attribute shall not be present, and the "value" and "use" attributes shall be present.
Treeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD.IPS1 … 1R(IPS...hor)
Included from 2.16.840.1.113883.10.22.11 IPS Address (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@use
set_cs0 … 1 
 CONF
The value of @use shall be drawn from value set 2.16.840.1.113883.1.11.10637 PostalAddressUse (2005‑05‑01)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@nullFlavor
cs0 … 1FNI
 ConstraintSHALL NOT have mixed content except for white space
If there is no information, the nullFlavor attribute shall have a value of 'NI' and no address parts shall be present, otherwise there shall be no nullFlavor attribute, and at least one of the address parts listed below shall be present.
 Schematron assertrole error 
 test@nullFlavor or hl7:* 
 MessageIf addr is not nullflavored at least one sub element has to be provided 
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:streetAddressLine
ADXP0 … *CSubject's or Organization's Street Address Line(IPS...hor)
 Schematron assertrole error 
 testhl7:streetAddressLine and (hl7:city or hl7:postalCode) 
 MessageIf the address line is included either the city or the zip code has to be provided 
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:city
ADXP0 … 1CSubject's or Organization's City(IPS...hor)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:postalCode
ADXP0 … 1CSubject's or Organization's Postal Code(IPS...hor)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:state
ADXP0 … 1CSubject's or Organization's State or Province(IPS...hor)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:country
ADXP0 … 1CSubject's Country.(IPS...hor)
 ConstraintThe content of this element SHALL be selected EITHER from ValueSet ISO Country Alpha-2 urn:oid:2.16.840.1.113883.1.11.20300  DYNAMIC OR MAY be selected from ISO Country Alpha-3 2.16.840.1.113883.1.11.171 DYNAMIC, IF the country is not specified in ValueSet ISO Country Alpha-2 urn:oid:2.16.840.1.113883.1.11.20300.